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The University of the State of New York THE STATE EDUCATION DEPARTMENT Office of Vocational and Educational Services for Individuals with Disabilities Strategic Evaluation Data Collection, Analysis and Reporting One Commerce Plaza – Room 1613 Albany, NY 12234-0001 PD-1C/4C-Charter School Report: Number of Students with Disabilities Provided Special Education on December 1, 2004 and the Settings in which School-Age Students with Disabilities are Provided Special Education Services Instructions: 1. Return one copy of this report between December 1 and December 17, 2004 to the above address. (This report may not be signed or submitted prior to December 1, 2004.) 2. Retain one copy (and supporting documentation) in your Charter School for reference and audit purposes. The required retention period ends June 30, 2011. 3. If you have questions about this report, please call (518) 486-4678, or e-mail your questions to [email protected] School Information (Enter 12-digit SED Code Below)

SCHOOL NAME ADDRESS (include building name, room number, or mail stop information)

CITY STATE ZIP Contact Person Information* NAME TITLE TELEPHONE (Include Area Code) FAX E-MAIL ADDRESS *All correspondence from the address at the top of this page will be directed to the contact person reported in the PD web-based system at http://pd.nysed.gov. You may update the contact person at any time through the PD web-based system located at http://pd.nysed.gov.

Certification and Assurances I have reviewed the information reported on this form and certify that this is a complete and accurate count of students with disabilities served on December 1, 2004. I further certify that the students reported were enrolled in this Charter School, had a current Individualized Education Program and received special education programs or services in accordance with State standards.

I understand that the sub-allocation of federal funds to this Charter School will be based upon this count. If the reported count is lower than the actual count, additional funds will not later be claimed. If the reported count is higher than the actual count, a downward revised PD-1C/4C report will be submitted to the School District(s) of students’ residence and to the State Education Department, and funds received for those erroneously counted will be returned to the appropriate school district(s).

I assure that federal, State and local procedures will be completed to receive a sub-allocation of IDEA funds from each school district of students’ residence. Chief School Administrator Must Sign ______and Date on or after Original Ink Signature Date Signed December 1, 2004.

______Name of Chief School Administrator

of 12 PD-1C/4C (9/04) (Please type or print) Directions for Completing the PD-1C/4C Report

1. Report information for all preschool and school-age students with disabilities enrolled in your approved charter school on December 1, 2004. 2. Wherever information is requested regarding students' race/ethnicity, please use the definitions below to assist in determining the most appropriate category for reporting students. Also, the race/ethnicity of students must be reported consistently on all Department data collection instruments. American Indian/Alaskan Native: A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment. Asian or Pacific Islander: A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. The Pacific Islands include Hawaii, Guam, and Samoa. Black or African American (not Hispanic): A person having origins in any of the Black racial groups of Africa. Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. White (not Hispanic): A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. 3. Wherever students are to be reported by age, please report age as of December 1, 2004. 4. If specific instructions for some tables are not provided below, they are included above each table of the PD-1C/4C form.

Directions for Selected Sections and Tables

Section B, Table 1: Provide the number of students with disabilities by public school district of residence by age ranges 4-5 and 6-21. Report all students with disabilities who are enrolled in the Charter School and who are provided special education services by the Charter School or by the public school district. The total number of students reported in this table must be equal to the number of students reported in Section A, Table 1, Line 4. This report must be submitted to the State Education Department and also to each school district of residence to assist them with sub-allocating a proportionate share of federal IDEA funds under Sections 611 and 619 for each Charter School.

Section C, Report 1, Table 1: Report the number of students with disabilities who are educated in regular school buildings and removed from regular classes for "Less than 20%", "21% to 60%", or "More than 60%" of the school day or school week. "Regular school buildings" are buildings for both disabled and non-disabled school-age students. "Regular classes" are classes for both disabled and non-disabled school-age students. Time outside of regular classroom is a measure of the extent of removal from the regular classroom setting, NOT of the total amount of special education services provided. It is the percent of each school day or week that a student receives special education including related services, apart from non-disabled students while within a regular school building. For purposes of these data collection, students in the following settings should be reported in Table 1 (regular school buildings):

 Students who are receiving transition support services.  Students who attend regular school buildings for at least 50 percent of the school day or school week, even though they may attend programs in separate settings that include only students with disabilities for the rest of the day or week.  All Charter School buildings that are attended by both disabled and non-disabled school-age students.  All public school buildings that are attended by both disabled and non-disabled school-age students.  All BOCES buildings that are attended by both disabled and non-disabled school-age students. Page 2 of 12 PD-1C/4C (9/04)  All Alternative High School programs that are attended by both disabled and non-disabled students.  All age appropriate community-based settings that include individuals with and without disabilities, such as vocational sites, in which students with disabilities interact with non-disabled individuals other than non- disabled individuals who are providing services to the students.

In order to determine the percent of time students receive services outside regular classrooms (i.e., in rooms/groupings attended by students with disabilities only), it is important to consider where the service is provided rather than the type of service that is provided. To calculate the percentage of time outside the regular classroom, divide the number of hours the student receives special education and related services outside the regular classroom each day or week by the total number of hours in the school day or school week. Use the length of the entire school day, including all periods and lunch. The following examples are provided for purpose of clarification:

 A student who attends a resource room for one period each day in which special education services are provided to a group of students with disabilities would be counted in Table 1, Line 1 since one period outside of regular classroom would constitute 20 percent or less of the school day.  A student who is assigned a full-time, one-to-one teacher aide, but who attends regular classrooms for 80 percent or more of the school day should be included in Line 1 of Table 1.  A student who receives special education services for two hours per day outside of regular classrooms would be reported on Table 1, Line 2. If the two hours of special education services are provided in the regular classroom, the student should be reported in Table 1, Line 1.  A student whose first period begins at 8:30 a.m. and last period ends at 2:30 p.m. would have a six-hour day or 30-hour week. If the student attended a special class for four 45-minute periods daily and participated in the general education environment for the remainder of the day, that student’s “time outside regular classroom” would be 15.0 hours per week or 50 percent of the week. Such a student would be reported in Table 1, Line 2.  Special education services provided outside the normal school day (e.g., before school or after school) should not be considered time outside the regular classroom, regardless of the type of services or where they are provided. Such students should be counted in Table 1, Line 1.  Students with disabilities who receive special education programs or services in regular classes that include non-disabled students should be reported in Table 1. This includes regular classrooms in which consultant teachers provide special education programs and services or regular classes in which special class programs are located. Section C, Report 1, Table 2: Report the number of students with disabilities who are educated in separate educational settings. These are settings that are attended by students with disabilities only. The definition of each separate educational setting follows:

Special Public Day Schools- Include public day schools that are attended by students with disabilities only. These schools include public school district or Charter School or BOCES buildings that are attended by students with disabilities only.

of 12 PD-1C/4C (9/04) Charter School Name:______SED Code:______

Section A, Table 1: School-Age Special Education Programs and Services  Provide an unduplicated count of all school-age students with disabilities enrolled in this Charter School on December 1, 2004, and provided special education services in accordance with Individualized Education Programs (IEPs).  Include students provided special education services or programs as defined in Section 200.6 of the Regulations of the Commissioner of Education. This includes Transitional Support Services, Consultant Teacher Services, Related Services, Resource Room Programs, and Special Class Programs.  Do not include students who are determined to have a disability pursuant to Section 504 of the Rehabilitation Act of 1973, unless the student is also determined to have a disability pursuant to the Individuals with Disabilities Education Act and Part 200 of the Regulations of the Commissioner of Education.  If a student receives special education services in accordance with an IEP, from the Charter School as well as from the school district of residence, report the student in Line 1 and not in Line 2 below. Line Report Each Student Only Once Ages 4-5 Ages 6-21 1 Count of school-age students with disabilities enrolled in this Charter School and provided special education programs or services by personnel employed or contracted by the Charter School. 2 Count of school-age students with disabilities enrolled in this Charter School and provided special education programs or services by personnel employed or contracted by the public school district. 3 Count of all school-age students with disabilities enrolled in this Charter School (Sum of Lines 1 and 2). 4 Total count of school-age students with disabilities (ages 4-21) (Sum of the two columns of Line 3) enrolled in this Charter School. 5 Of the count of all school-age students with disabilities reported in line 4 above, report the number of such students who are 14 years of age or older, on December 1, 2004. 6 Count of all school-age students (ages 4-21) enrolled in this Charter School on December 1, 2004. (This count includes students with disabilities, general education students, gifted students, etc.).

Please note: The Subtotal of Section A, Table 1, Line 4 must be identical to the Total of Section A, Table 2, Line 14 on the next page.

Please proceed to next page

of 12 PD-1C/4C (9/04) Charter School Name: ______SED Code: ______

Section A, Table 2: School-Age Special Education Programs and Services For students reported in Section A, Table 1, Line 4 (i.e. all school-age students with disabilities enrolled in this Charter School), provide the same count by age and disability. Please group students counted by their actual age on December 1, 2004 (e.g., a student who is 12 years and 10 months on December 1, 2004 is counted as age 12). Any student classified as both Deaf and Blind must be reported as “Deaf–Blindness” on Line 12. Number of Students by Age on December 1, 2004 Line Disability Category 4-5 6-11 12-13 14-17 18-21 Total No. Years* Years Years Years Years 1 Autism 2 Emotional Disturbance 3 Learning Disability 4 Mental Retardation 5 Deafness 6 Hearing Impairment 7 Speech or Language Impairment 8 Visual Impairment (includes Blindness) 9 Orthopedic Impairment 10 Other Health Impairment 11 Multiple Disabilities 12 Deaf-Blindness 13 Traumatic Brain Injury 14 Total – Lines 1 through 13

Please note: The Total of Section A, Table 2, Line 14 must be identical To the Subtotal in Section A, Table 1, Line 4 on the previous page.

of 12 PD-1C/4C (9/04) The University of the State of New York THE STATE EDUCATION DEPARTMENT Office of Vocational and Educational Services for Individuals with Disabilities CHARTER SCHOOL PD-1C/4C REPORT OF NUMBER OF STUDENTS PROVIDED SPECIAL EDUCATION ON DECEMBER 1, 2004

Section B, Table 1: Report of Students with Disabilities by School District of Residence

Charter School Name:______SED Code: ______

Charter School Address: ______

______

Charter School Contact Person______

Charter School Contact Person’s Telephone: ______

Charter School Contact Person's Telefacsimile Number: ______

Charter School Contact Person’s E-Mail Address: ______

Enter special education child count information for all school-age students with disabilities enrolled in this Charter School, according to each public school district in which such students reside on December 1, 2004. Information contained in this Table should be submitted to each school district in which students with disabilities reside. Information contained in this table will assist school districts to sub-allocate federal funds under IDEA, Sections 611 and 619 to the Charter Schools. Please duplicate this page if your Charter School serves students with disabilities from more than one school district. Also, please note, the total number of students reported below, by school district in Line 5, must equal the total number reported in Section A, Table 1, Line 4.

1. Public School District Name: BEDS Code:

Ages 4-5 Ages 6-21 2. School-age students with disabilities, provided special education by Charter School

3. School-age students with disabilities, enrolled in the Charter School but provided special education by the public school district.

4. Count of all school-age students with disabilities, (Sum of Lines 2 and 3)

5. Total count of all school-age students with disabilities, ages 4-21. (Sum of both columns of Line 4).

Please duplicate this page and complete it for each school district of residence of students with disabilities. The total number of students reported on all such pages should be equal to the number of students with disabilities reported in Section A, Table 1, Line 4.

of 12 PD-1C/4C (9/04) Charter School Name: ______SED Code: ______

Section B, Table 2: School-age Students with Disabilities who are also Students with Limited English Proficiency (Also referred to as English language learners.) Of the school-age students with disabilities reported in Section A, Table 1, Line 4, report the subset of such students having limited English proficiency (LEP) in Line 1 below. Such students should be reported based on LEP designation, regardless of the extent or type(s) of LEP services provided. (December 1, 2004 should be used in determining student age.)

Students determined to have a disability pursuant to Section 504 only, and do not have an IEP developed by a Committee on Special Education, should not be reported in this section, regardless of LEP status. Line 4 – 5 6 – 11 12 – 13 14 – 17 18 – 21 Description Total No. Years Years Years Years Years School-Age LEP Students with 1 Disabilities

Section B, Table 3: Test Accommodations for Students with Disabilities Of the school-age students reported in Section A, Table 1, Line 4, enter the number of students whose individualized education programs (IEPs) include one or more testing accommodations, by the appropriate age interval, in Line 1. Students should be reported once, regardless of the number of testing accommodations listed in their IEP's. Also, all students should be reported regardless of whether they will be administered a State assessment during the 2004-2005 school year. Line Students Ages Students Ages Students Ages Description No. 4 – 12 13 – 15 16 – 21 Total number of students with disabilities provided any 1 type(s) of testing accommodations

Section B, Table 4: Students Provided Section 504 Accommodations Number of school-age students provided "reasonable accommodations" pursuant to Section 504 of the Rehabilitation Act of 1973. Students should be reported if they were determined to have a disability by a Section 504 Multidisciplinary Team and provided services/accommodations specified in a Section 504 Accommodation Plan on December 1, 2004. (December 1, 2004 should be used in determining student age.) This data category is being implemented for program planning purposes only. It will not affect this Charter School's IDEA sub-allocations in any way. (Please note that students included in Section A of this report are not to be counted in this Table, even if they qualify to be counted for both.) Line Disability 4-5 6-11 12-13 14-17 18-21 No. Category Years Years Years Years Years Total 1 Section 504 Disability

of 12 PD-1C/4C (9/04) Section B, Table 5: School-Age Students with Disabilities by Grade or Age For all students with disabilities reported in Section A, Table 1, Line 4 report the number of students by grade level in Part 1 below. For students with disabilities who are not enrolled in a grade, report them in Part 2 below by age. Each student with a disability is to be reported in only one Line of either Part 1 or Part 2. Assignment of students with disabilities should be reported by grade if students attend classes with a particular grade. If students with disabilities attend classes with more than one grade, report them in the grade that they attend for majority of their classes, or the grade with which they identify. Please note the total number of students with disabilities in Line 14 of Part 1 plus the total number of students with disabilities in Line 16 of Part 2 must equal the total number of students with disabilities reported in Section A, Table 1, Line 4. Part 1 - Number of Students with Disabilities in Each Grade- Part 2 - Number of Students with Disabilities who are not Regardless of Age Assigned to a Grade, by Age as of 12/01/04 Number of Students with Number of Students with Line # Grade Line # Age Disabilities Disabilities 1 Kindergarten 1 Age 4

2 Grade 1 2 Age 5

3 Grade 2 3 Age 6

4 Grade 3 4 Age 7

5 Grade 4 5 Age 8

6 Grade 5 6 Age 9

7 Grade 6 7 Age 10

8 Grade 7 8 Age 11

9 Grade 8 9 Age 12

10 Grade 9 10 Age 13

11 Grade 10 11 Age 14

12 Grade 11 12 Age 15

13 Grade 12 13 Age 16

14 Total 14 Age 17

15 Ages 18-21

16 Total

of 12 PD-1C/4C (9/04) Section C: Settings in which School-Age Students with Disabilities are Provided Educational Programs or Services and Race/Ethnicity Information

Report 1: Report of All School-Age Students with Disabilities Placed as of December 1, 2004

Directions: Please review directions and definitions for completing Section C, Report 1 beginning on page 2.

In the two tables below, report placement data for all students with disabilities who attend the school-age program operated by this Charter School and receive special education programs/services based on an IEP. The students reported in Tables 1 and 2 below, must also be reported in Reports 2, 3 and 4 of this Section C. Please note that the total number of students with disabilities reported in Tables 1 and 2 below must be equal to the number of school-age students reported in Section A, Table 1, Line 4 of this report.

Table1: In Regular School-Based Programs - In buildings attended by both general education students and students with disabilities. (Consultant Teacher, Resource Room, Special Class, et. al.)

A B C D E F Line Age Group Time OUTSIDE Regular Classroom Number 4-5 6-11 12-13 14-17 18-21 Total 01 20% or less 02 21% to 60% 03 More than 60% 04 Total

Table 2: In Separate Settings - In buildings attended by students with disabilities only (outside of regular school facilities).

A B C D E F Line Age Group Number Type of Setting 4-5 6-11 12-13 14-17 18-21 Total 01 Special Public Day School 02 Total

Note: The totals for each line in Tables 1 and 2 above should be identical to the totals for each line in Tables 1 and 2 of Report 2 on the next page.  The total for Table 1 plus Table 2 above should equal the total reported in Section C, Report 3, Line 14.  The total number of students in Columns D and E of Table 1 and Table 2 above must be equal to Section A, Table 1, Line 5 and also equal to the total number of students in Section C, Report 4.

of 12 PD-1C/4C (9/04) Section C: Settings in which School-Age Students with Disabilities are Provided Educational Programs or Services and Race/Ethnicity Information

Report 2: Report of All Students with Disabilities as of December 1, 2004, by Race/Ethnicity Category and Type of Setting in which Educational Services are Provided

For all students reported in Section C, Report 1, Tables 1 and 2, enter the number of students who appear to belong, identify with, or are regarded in the community as belonging to each race/ethnic group. Please see page 2 for definition of each race/ethnic category. Each student should be counted only once. The Total (Column F) of each line in this report must match the Total (Column F) of each line in Report 1 on the previous page.

Table1: In Regular School-Based Programs - In buildings attended by both general education students and students with disabilities. (Consultant Teacher, Resource Room, Special Class, et. al.)

A B C D E F Time American OUTSIDE Asian or Black (not White (not Indian or Line Regular Pacific of Hispanic Hispanic of Hispanic Total Alaskan Number Classroom Islander origin) origin) Native 01 20% or less

02 21% to 60%

03 More than 60%

04 Total

Table 2: In Separate Settings - In buildings attended by students with disabilities only (outside of regular school facilities).

A B C D E F American Type of Asian or Black (not White (not Indian or Line Setting Pacific of Hispanic Hispanic of Hispanic Total Alaskan Number Islander origin) origin) Native Special Public 01 Day School

02 Total

of 12 PD-1C/4C (9/04) Section C: Educational Placement of School-Age Students with Disabilities and Race/Ethnicity Information

Report 3: Report of All Students with Disabilities as of December 1, 2004, by Race/Ethnicity Category and Type of Disability

In the table below, report race/ethnicity data by disability for all students reported in Section C, Report 1, Tables 1 and 2. Also, the total number of students with disabilities reported in this report must equal the total number of students with disabilities reported in Section A, Table 1, Line 4. Furthermore, the total number of students reported in Columns A-F below must match the total number of students reported on the corresponding column totals of Table 1 plus Table 2 from Report 2.

Race/Ethnicity Category A B C D E F Line American Black White Disability Asian Number Indian or (not of (not of or Hispanic Total Alaskan Pacific Hispanic Hispanic Native Islander origin) origin)

of 12 PD-1C/4C (9/04) 01 Autism

02 Emotional Disturbance

03 Learning Disability

04 Mental Retardation

05 Deafness

06 Hearing Impairment

07 Speech or Language Impairm ent 08 Visual Impairment (include s Blindne ss) 09 Orthopedic Impairment

10 Other Health Impairment 11 Multiple Disabilities

12 Deaf-Blindness

13 Traumatic Brain Injury

14 Total (Lines 1-13)

Please proceed to next page Section C: Educational Placement of School-Age Students with Disabilities and Race/Ethnicity Information

Report 4: Report of Students with Disabilities who are 14-21 years of age as of December 1, 2004, by Race/Ethnicity Category. (These students are a sub-set of the students reported in Section C, Reports 1, 2 and 3.)

In the table below, report race/ethnicity data for students with disabilities (ages 14-21) enrolled in the Charter school. The total number of students reported in this table must equal the total number reported in Section A, Table 1, Line 5 and also equal to the total number of students reported in Section C, Report 1, Table 1 and Table 2, Columns D and E.

Race/Ethnicity Category A B C D E F Line American Black White Category of Students Asian or Number Indian or (not of (not of Pacific Hispanic Total Alaskan Hispanic Hispanic Islander Native origin) origin) Students with Disa biliti 01 es, Age s 14- 21

of 12 PD-1C/4C (9/04)